Autistic traits in schizophrenia: meta-analysed

"Current findings support that individuals with schizophrenia spectrum disorders have higher autistic symptoms than healthy controls."

So said the meta-analysis findings reported by Franco De Crescenzo and colleagues [1] and their study which "systematically reviews and quantitatively synthetizes the current evidence on the presence of autistic symptoms in individuals with schizophrenia spectrum disorders." I might quibble (again) with the use of the term 'healthy controls' but the findings reiterate something quite important: autistic signs and symptoms are not necessarily exclusively linked to a diagnosis of autism (see here and see here).

The De Crescenzo paper represents a 'let's boil down the existing peer-reviewed science literature into a coherent statement' kinda study; as 13 studies including nearly 2000 participants were included for review and meta-analysis. The primary outcome "was the Autism Spectrum Quotient (AQ)" and its use on those diagnosed with schizophrenia or schizophrenia spectrum disorder (SSD) vs. those with autism or vs. those asymptomatic controls as a total score or scores on the various sub-domains. The results went something along the lines of "individuals with SSDs have significantly higher autistic symptoms than healthy controls and lower autistic symptoms than individuals with autism." That finding followed for the total AQ score and most of the sub-domain scores.

What else is there to say? Well, the De Crescenzo results relied on the AQ for their measurement of autistic signs and symptoms. I've mentioned more than once on this blog how the AQ might show an important connection to autism but is not necessarily the premier (exclusive) autism screener (see here and see here). Applying such logic to the current meta-analysis findings and one has to be a little bit careful about what is being measured by such a scale and whether such overlap is there on the basis of just autistic signs and symptoms.

That all being said I have talked about overlap between scores on the AQ in autism and schizophrenia before on this blog (see here) and the notion of potential 'fuzzy boundaries' between the two labels. Indeed, it makes you wonder whether science and clinical practice were too quick to dismiss the important findings from Mildred Creak and colleagues [2] and the seeming desire to move autism as far away from schizophrenia as possible...

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[1] De Crescenzo F. et al. Autistic Symptoms in Schizophrenia Spectrum Disorders: A Systematic Review and Meta-Analysis. Front Psychiatry. 2019;10:78.

[2] Evans B. How autism became autism: The radical transformation of a central concept of child development in Britain. Hist Human Sci. 2013;26(3):3-31.

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Subclinical autistic traits affecting adolescent sleep patterns?

There was something rather intriguing about the results published by Liisa Salmela and colleagues [1] (open-access available here) observing that: "Elevated levels of autistic traits were significantly associated with shorter weekday sleep duration" in a cohort of adolescents from Helsinki in Finland. The fact that researchers also concluded that "autistic traits remained an independent predictor of short sleep duration when comorbid psychiatric symptoms were controlled for" added to the intrigue.

I was impressed with some elements of the Salmela study; notably the use of actigraphy as an objective measure of sleep accompanying self-report data derived from the Pittsburgh Sleep Quality Index (PSQI). The fact that actigraphs were worn "continuously for an average of 8.36 nights (SD = 1.76; range 4–17)" also meant that researchers had access to quite a bit of data from their 150+ participant study group when it came to activity cycles covering sleep.

What was the measure of autistic traits used I hear you ask? Well, we are told that: "Autistic traits were assessed using the Autism Spectrum Quotient (AQ)" which is an OK measure I suppose, although not without some shortcomings in terms of what is being specifically measured (see here). I should also mention that for the most part, the Salmela study was a study of non-autistic adolescents (two participants were reported to have "scored at or above the clinical cut-off score of 32" on the AQ).

"Continuous autistic traits significantly predicted weekday total sleep time" and "having elevated autistic traits as measured by AQ (Autism Spectrum Quotient) increased the risk for short sleep duration." Mindful that correlation is not necessarily the same as causation, details were important to the Salmela findings as we are also told that (a) as a group, boys tended to score higher on the AQ and (b) again as a group "boys had significantly shorter weekday total sleep time" than girls. It's perhaps no surprise therefore that: "Sex had a statistically significant main effect (p = 0.032) on total sleep time."

Next question: why? Why should autistic traits potentially "increase the risk for short sleep duration in a general adolescent population"? Is there something about the presentation of autistic traits that affects sleep either through psychological/cognitive processes or more physiological processes? Well, those are questions that still need answering. And alongside we seem to have yet another example where core autistic features may very well impact on so-called comorbid issues to add to the collection (see here and see here). This also has potential implications for intervention too...

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[1] Salmela L. et al. Autistic traits and sleep in typically developing adolescents. Sleep Med. 2018 Oct 29;54:164-171.

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"hold promise as cross-cultural key indicators for autism"

The quote heading this post - "hold promise as cross-cultural key indicators for autism" - comes from the paper by Sophie Carruthers and colleagues [1] which "aimed to identify the items on the Autism Spectrum Quotient (AQ)-Child that are most predictive of an autism diagnosis among children aged 4–9 years across samples from India, Japan and the UK." Attempting to fill quite an important 'hole' in the use of the go-to 'are you autistic' screener, authors set out to look at the presentation of autistic traits across three different countries, all with some quite different cultural perspectives and contexts.

The Carruthers paper is open-access so doesn't need too many grand discussions from me. The basics: "parent-reported AQ-Child data from India (73 children with an autism diagnosis and 81 neurotypical children), Japan (116 children with autism and 190 neurotypical children) and the UK (488 children with autism and 532 neurotypical children)" was the source material. Once again I'll mention how the term neurotypical is a misnomer (see here); it's use in this paper is all the more surprising given that one of the authors wrote an editorial paper [2] mentioning how "there is no single way for a brain to be normal, as there are many ways for the brain to be wired up and reach adulthood." Oh well.

Results: from the collected data, researchers were able to undertake various statistical analyses. Pertinent to the quote titling this post were some important findings "identified to be universal key indicators" across the different countries and cultures. These were: "In a social group, s/he can easily keep track of several different people’s conversations; s/he enjoys social chit-chat; s/he knows how to tell if someone listening to him/her is getting bored; s/he is good at social chit-chat and s/he finds it difficult to work out people’s intentions." Alongside, various other indicators were rated as "performed excellently or acceptably" across the three different country groups.

The conclusion: "Cross-cultural overlap in the items most predictive of an autism diagnosis supports the general notion of universality in autistic traits whilst also highlighting that there can be cultural differences associated with certain autistic traits." I'd like to see more research done in this area. Quite a few years ago I posed the question 'Is autism the same all over the world?' (see here) and well, I don't have a good answer despite the Carruthers and other results. Obviously such a question needs also to be wrapped in the idea that the plural 'autisms' also exert an effect (see here) and take into account other factors such as comorbidity (if that is the right word). It should also perhaps appreciate that whilst the AQ is undoubtedly 'picking up' something, it might not just exclusively be autism or autistic traits (see here and see here)...

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[1] Carruthers S. et al. A cross-cultural study of autistic traits across India, Japan and the UK. Molecular Autism 2018; 9:52.

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Big data does... the extreme male brain theory of autism and the Empathizing–Systemizing theory

"Two long-standing psychological theories – the empathising-systemising theory of sex differences and the extreme male brain theory of autism – have been confirmed by our new study, the largest of its kind to date."

That was the opening sentence to a write-up (see here) of a recent research paper published by David Greenberg and colleagues [1] which sought to "test 10 predictions from the Empathizing–Systemizing (E-S) theory of sex differences and the Extreme Male Brain (EMB) theory of autism." The 'big data' words included in the title of this post refer to the collection of data from hundreds of thousands of people as part of a TV documentary that aired here in Blighty called 'Are you autistic?' whose data were included for study. This follows a similar format from some of the co-authors on the Greenberg paper on previous research occasions (see here).

Minus any charges of plagiarism, a few descriptors might be useful. First: "The first theory, known as the empathising-systemising theory of typical sex differences, posits that, on average, females will score higher on tests of empathy than males, and that, on average, males will score higher on tests of systemising than females." Second: "The second theory, known as the extreme male brain theory of autism, extends the empathising-systemising theory. It posits that autistic people will, on average, show a shift towards “masculinised” scores on measures of empathy and systemising." Researchers also talked about something called a 'd score': "the difference between each person’s score on the systemising and empathy tests" in their research, alongside mention of the words 'brain type'.

As part of the interactivity of that TV documentary, some 670,000 people "who indicated they were males or females" completed various measures: "the Autism Spectrum Quotient-10 (AQ-10)... the Empathy Quotient (EQ)..., Systemizing Quotient-Revised (SQ-R)..., and the Sensory Perception Quotient (SPQ)" via an on-line questionnaire portal. About 36,000 people who took part "indicated that they had been diagnosed with an “Autism Spectrum Condition”." Data from responses to the questionnaires were crunched pertinent to those 10 predictions from both theories (said predictions concerned sex differences based on responses to the questionnaires, those various 'brain types' and how responses might look with reference to the presentation of autistic traits). For good measure, researchers also describe carrying out an 'independent replication' of their findings on a separate cohort of adults ("14,354 participants (226 autistic individuals, and 14,119 controls)"). Although there were some minor differences from the larger main trial, to all intents and purposes the same procedures were employed "for calculating brain types and performing statistical analysis."

Results: well "all 10 predictions from the E-S and EMB theories" were confirmed. So for example, men taking part in the study "had a shift towards a high d score" suggestive of being more likely to be systemisers than empathisers, whilst "typical females had a shift towards a low d score" (i.e. more likely to empathetic than systemiser). The previous STEM (science, technology, engineering, and mathematics) findings [2] were also supported, in that: "STEM professionals on average scored significantly higher on the AQ" suggesting a link between the choice of STEM career and autistic traits. And for those reporting a diagnosis of autism or autism spectrum disorder (ASD): "autistic people, regardless of their sex, had a shift towards an even higher d score than typical males" (systemisers) but "were not more likely to work in STEM occupations, compared with controls."

There is a lot to take in from the Greenberg research and related commentary. The study has a number of things going for it insofar as the huge participant size and the use of an independent replication set to confirm findings. These factors should not be underestimated. The limitations? Well, self-report is still one of them, and the fact that at least one of the questionnaires used is probably picking up a lot more than just 'autistic traits' (see here). I'm also inclined to point out once again that the *correlation* between autistic traits and STEM career choice did not seemingly extend to those with autism being "more likely to work in STEM occupations, compared with controls." Going back to that 'what is being tested' issue, the AQ for example, might also be picking up something linked to "loneliness, social anxiety, depression, and anxiety" [3] or even something approaching the schizophrenia spectrum (see here) or personality disorder (see here). Indeed, one might have to entertain the idea that the definition 'autistic traits' may not tell the whole story in this study.

I have to admit to being still a little sceptical of big psychological theories such as the EMB or the E-S theory of sex differences. The reason? Whilst attractive in their compartmentalising nature, real life is often far from being so clear-cut and linear. The fact also that an important part of the evidence behind such theories remains a little 'fluffy' (see here for example) cannot be readily brushed under the scientific carpet. As for the use of the term 'brain types', well, I can see what the authors were getting at, but I'm not convinced such terminology is particularly useful. 'Brain types' kinda sits in the same category as 'neurotypical' (see here). I was also drawn to the fact that the authors have to explicitly say that their results don't mean that "autistic people lack empathy" and that "autistic people are not hyper-male in general." It kinda tells you how some of the history behind these theories shows that they have not exactly been received with open arms by many.

But even with all that, the Greenberg results cannot be just discounted, and more research on this topic is indicated.

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[1] Greenberg DM. et al. Testing the Empathizing-Systemizing theory of sex differences and the Extreme Male Brain theory of autism in half a million people. Proc Natl Acad Sci U S A. 2018 Nov 12. pii: 201811032.

[2] Ruzich E. et al. Sex and STEM Occupation Predict Autism-Spectrum Quotient (AQ) Scores in Half a Million People. PLoS One. 2015 Oct 21;10(10):e0141229.

[3] Reed P. et al. Loneliness and Social Anxiety Mediate the Relationship between Autism Quotient and Quality of Life in University Students. Journal of Developmental and Physical Disabilities. 2016; 28: 723-733.

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"maternal pre-pregnancy obesity is associated with autism-like behaviors in offspring"

The results reported by Kandice Varcin and colleagues [1] concluding that "maternal pre-pregnancy obesity is associated with autism-like behaviors in offspring" continue and extend a research theme (see here and see here). A research theme that highlights a potentially important relationship between maternal weight (and/or related parameters) and offspring development across various, potentially intertwined, variables (see here).

Including the notable name of Andrew Whitehouse on the authorship team (see here and see here for some examples of his other research), researchers set about to explore whether "pre-pregnancy weight was related to autistic-like traits among offspring not diagnosed with ASD [autism spectrum disorder]." I added the bold highlight to the word 'not' to emphasise how this work was set slightly apart from the other research that has observed an *association* between maternal weight before or during pregnancy and a risk of a formal diagnosis of autism in offspring. Pregnant women in their second trimester of pregnancy were recruited and "had their height measured." They also "reported their pre-pregnancy weight" which combined with the height measurements to give the measure known as the body mass index (BMI). And also: "At 19-20 years of age, 1238 offspring of these women completed a measure of autistic-like traits, the Autism-Spectrum Quotient (AQ)." Keep those issues in mind for now.

Results: "Regression analyses identified a positive association between increasing maternal pre-pregnancy BMI and increasing AQ Total Score amongst offspring; this association was maintained even after controlling for a range of variables including maternal/obstetric factors (age at conception, education, smoking, alcohol consumption, hypertensive diseases, diabetes, threatened abortion), paternal BMI at pregnancy, and child factors (parity, sex)." Sorry for the large quote, but the authors said it better than I ever could. Authors also reported that those women defined as being obese before pregnancy, according to their BMI measurement, were quite a bit more likely to "have offspring with high scores (≥26) on the AQ." This then lead them to conclude that "maternal pre-pregnancy obesity is associated with autism-like behaviors in offspring."

Caveats? Well, yes, a few. Height measured in the second trimester but participants "reported their pre-pregnancy weight"? I can see a few complications there in terms of accuracy of recall and perhaps the possibility of some bias creeping in. Having said that, many mums-to-be do have records of their weight during that 'special time' and some probably before as part of their regular clinical care or just as a result of how health conscious everyone is being these days. That and the fact that most people roughly know their typical weight (outside of pregnancy).

But also the AQ... the AQ. Regular readers probably already know that I have some qualms about the AQ and it's 'specificity' when it comes to autism and autistic traits (see here and see here). I know it's often seen as one of the internet's premier 'are you autistic?' instruments, but sometimes I think it's done more harm than good by way of it's probable link to the rise and rise of the 'self diagnosis' (see here) for example. I could go on about this, but I won't. Instead I'll just mention that 'autism-like' behaviours as judged by the AQ is probably the correct phrase to use in the context of the Varcin paper. Indeed, one might easily suggest that in a non-clinical population, AQ might also be tapping into other labels and traits [2]: "Higher AQ scores were associated with higher scores of loneliness, social anxiety, depression, and anxiety, as well as with lower scores of quality of life (QoL)." So unless one accepts that depression and/or anxiety might potentially be core features of autism (see here and see here), AQ might be picking up other things other than autism.

Still, I can't argue with the *association* talked about by Varcin et al, and what it might mean for the quite spectacular rise and rise in the numbers of people being diagnosed with an autism spectrum disorder (see here). No, not by any means the only factor to account for the increase in diagnoses, but potentially an important part of the story...

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[1] Varcin KJ. et al. Maternal pre-pregnancy weight and autistic-like traits among offspring in the general population. Autism Res. 2018 Sep 19.

[2] Reed P. et al. Loneliness and Social Anxiety Mediate the Relationship between Autism Quotient and Quality of Life in University Students. Journal of Developmental and Physical Disabilities. 2016; 28: 723-733.

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More welcomed (and interesting) research on pathological demand avoidance (PDA)

Pathological demand avoidance (PDA) [syndrome] is a label that currently occupies an unusual place in psychiatric and developmental circles. Defined by "obsessive non-compliance, distress, and florid challenging and socially inappropriate behaviour", PDA has seemingly found a place (somewhere) on the autism spectrum, but at the time of writing, does not actually occupy any unique position in any of the current systems of diagnostic classification mentioning autism (e.g. DSM, ICD). The National Autistic Society (NAS) here in Blighty talk about PDA in the context of "a behaviour profile within the autistic spectrum" but that's just one description among others.

The rise and rise of the term PDA as a specific diagnosis is firmly rooted (geographically) here in Blighty. This is probably as a result of the first description of PDA emanating from the late Elizabeth Newson during her time at the Early Years Diagnostic Centre (now called the Elizabeth Newson centre). Not everyone however is totally convinced that PDA is an independent syndrome (see here) or indeed, whether it is deserving of its specific and exclusive link with the autism spectrum at the cost of other labels... I'll be touching on that last point again in this post.

After that long introduction, I bring the findings reported by Vincent Egan and colleagues [1] to the blogging table, and some more welcome research in this area. The name of the research game for Egan et al was to adapt the Extreme Demand Avoidance Questionnaire (EDA-Q) "an informant-rating instrument" into a self-report version - the Extreme Demand Avoidance Questionnaire—Adult version (EDA-QA). Two studies are reported on in this context: "In Study 1, we use this measure to examine the relationship between PDA traits, ASD [autism spectrum disorder] traits, and other psychopathology dimensions, in a community sample of adults reporting self-identified psychopathology" and: "The second study examined the EDA-QA in a community sample and measured ASD traits more thoroughly, using the full ASQ." Yes, that's ASQ as in AQ (the Autism Spectrum Quotient) "used to quantify cognitive and behavioural features associated with ASD" and all the baggage that goes with it (see here and see here).

Results: yes, the EDA-QA was "reliable, univariate, and correlated with negative affect, antagonism, disinhibition, psychoticism, and ASQ score." This bearing in mind that the nearly 350 people who took part in study 1 were all self-reporting on the various instruments used, were "recruited from a variety of specialist on-line blogs and community forums focusing on the needs and concerns of persons with ASD" and were described as "a highly educated group." I also note that the words 'self-identifying' were also used extensively during the study write-up, specifically: "29 individuals reporting self-identified ASD also reported having PDA, 44 persons claimed to have PDA alone, and a further 19 self-identified PDA alongside depression or anxiety; separately, 59 persons claimed to have formally diagnosed ASD." Even the authors acknowledge that "self-reported ASD is not without it’s difficulties." No arguments from me there (see here and see here) and others have similar opined.

When it came to study 2 results, we are told that: "A path analysis to fit the data indicated that ASQ and EDA-QA scores were positively related." Irrespective of my various musings on how the ASQ (AQ) is not seemingly 'specific' when it comes to traits being 'linked to autism', this is an encouraging result. But there was more too... "The EDA-QA measure was associated with lower agreeableness, lower emotional stability, and higher scores on the ASQ. The effects were stronger for personality traits than for ASQ scores, suggesting it may be personality that differentiates how ASD traits are expressed, with more emotionally unstable and antagonistic persons with ASD expressing PDA-type qualities." One of the thoughts I had about this finding - 'personality that differentiates how ASD traits are expressed' - is the 'tie up' between the expression of autistic traits in relation to something like borderline personality disorder (BPD) (see here and see here) that has become more frequent in the peer-reviewed science arena recently. Yet more evidence perhaps that 'self-identifying' or 'self-diagnosis' when it comes to autism is not necessarily the most accurate measure?

The authors conclude that their instrument has promise and "could be easily integrated into assessment packages currently used with prisoners, mentally disordered offenders, and homeless people, where PDA may be suspected." Minus any big headlines regarding those particular groups (see here for example), I think examination of PDA in some of those contexts could be rather revealing. The link, for example, between PDA and offending behaviour (see here) in the context that SRED (Self-Report Early Delinquency Scale) scores - indicating "higher overall self-reported delinquency" -  significantly positively correlated with EDA-QA is an intriguing finding. That also AQ scores showed no such association with SRED scores might also suggest that PDA is not as necessarily well suited to an all-encompassing link to autism (autistic traits) as many people might think...

Let's hope that there is more research to come on the topic of PDA.

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[1] Egan V. et al. The Measurement of Adult Pathological Demand Avoidance Traits. J Autism Dev Disord. 2018 Aug 23.

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Statistically significant group differences in self-reported repetitive movements between diagnosed and self-identifying autism

One needs to remember that, at the time of writing this post, the article posted by Joost Wiskerke and colleagues [1] suggesting that "camouflaging of RMs [repetitive movements] may contribute to under diagnosis of autism, at least in females and transgender people" is just a preprint ("a version of a scholarly or scientific paper that precedes publication in a peer-reviewed scholarly or scientific journal"). It has not been through formal peer-review yet, but rather the authors have bravely 'put it out there' for old farts like me to pore over.

Having glanced through the abstract first and discovered the use of the words "self-identified as autistic" my brow furrowed somewhat. Upon further reading of the paper in its entirety, the furrowing brow furrowed a little less as I understood why the authors mentioned use of a cohort that was "56% formally diagnosed participants and 44% who self-identified as autistic." But that's not to say that I was completely enamoured with the study write-up as it currently stands...

Before continuing and in order to repel any accusations that come my way, I'll mention that I don't have any particular issue with people without a formal diagnosis of autism thinking/believing they are on the autism spectrum. It's their right to do so and indeed, such self-realisation is often an important step towards getting a professional assessment for autism. For some people, their hunch about being autistic eventually turns out to be correct as per them reaching defined clinical cut-off points for autism on the various instruments of assessment that are available during said professional assessment. But that's not to say that every person who self-identifies as being autistic/having autism is always going to be right. As we are starting to realise from the wealth of peer-reviewed science on this topic, the label autism does not seemingly have any exclusive rights to the presentation of autistic traits (see here and see here for examples). And it is for that reason why we have so many good and knowledgeable diagnosticians when it comes to such professional assessments, combined with an important focus on: "Symptoms caus[ing] clinically significant impairment in social, occupational, or other important areas of current functioning" in order to receive a diagnosis. Access to such autism assessments is another issue, but shouldn't be used as an excuse...

Onward:

Wiskerke et al started from the premise that repetitive movements (RMs) are common in autism but there are some potentially important differences in the expression of such issues between the genders. This follows other independent findings in this area (see here) detailing how stereotyped and repetitive behaviours may be less frequently observed in females [2] minus any sweeping generalisations. Researchers then moved on to suggesting that one of the reasons why such RMs may be less frequently observed is because they are actively being masked or camouflaged, and this could eventually lead to an under-diagnosis of autism among certain groups. 'Masking' or camouflaging in the context of autism is a bit of a hot [social media] topic at the moment (see here and see here).

"In this exploratory study, we took a first step... by using self-report measures from a large number of female and transgender adults, using recruitment on social media to an on line questionnaire." Ah yes, the on line questionnaire, which seems to becoming more and more popular in certain autism research circles [3] (see here also for another example). There's nothing wrong with using such tools for asking about opinions and the like, but they are typically open to anyone and everyone (who has access to the internet!), and not exactly great for authenticating complicated things like clinical diagnoses, behaviours and comorbidity for example. As for the incorporation of data from transgender adults, well, again this follows a theme in autism research recently (see here) where 'autistic identity' and sexual identity seem to be converging for some people/groups (see here).

"We assessed current RMs using a combination of visual analog scales for specific behaviors and textboxes for free-text responses." There's mention of using some of the DSM-5 criteria for autism in this section. Authors also talk about testing for camouflaging "using the matrix multiple-choice question “Did/do you hide these behaviors from others…” 1) “…as a child?”, 2) “…as an adolescent?”, 3) “…as an adult?”" Yet again (see here) a research priority needs to be the formulation of a valid and reliable questionnaire pertinent to 'measuring' masking/camouflaging with autism in mind. And finally there was the use of an old favourite  - the autism spectrum quotient (AQ) - by the authors, but with some added caveats...

Results:  "We found high rates of RMs in both diagnosed and self-identifying participants, and a striking prevalence of camouflaging" was one of the headlines. But... there were also some other important details observed too. So: "Higher scores in the diagnosed group were found for object fidgeting, repetitive hand movements, rocking, object spinning and hand flapping." I think most people would agree that such behaviours represent some of the more 'classical' manifestations included in the RM categorisation of autism. By contrast, other RMs such as scratching/rubbing skin, walking in circles and 'banging head' were not different between the diagnosed and self-identifying groups.

Based also on the strength of the camouflaging data presented by Wiskerke et al I have to say that I'm not yet altogether convinced by the evidence presented. It's not that I don't believe that 'self-inhibition' plays a role in such masking, nor that: "There were many references (47 participants) to having been bullied or disciplined for childhood RMs." It's just that methodologically speaking, offering up one question on such a complicated issue does not make for a scientifically compelling argument. As I previously said, autism science needs to invest in some high quality research on how to assess masking in the context of autism; perhaps including some important measure of self-monitoring for example. And one also needs to control for things like intellectual ability too and perhaps be open to other reasons why the presentation of autism between the genders/sexes might be subtly different.

I was also a little dismayed that the discussion of results by the authors did not seem to fully 'tally' with their findings. So: "The striking similarities between diagnosed and undiagnosed participants are consistent with a clinically relevant prevalence of autism in the undiagnosed group." As I've mentioned, the picture of 'striking similarities' was far from consistent when comparing RMs across the groups and those statistically significant differences reported on between diagnosed and self-identifying autism. Added to the fact that authors zoomed in on RMs without too much clinical focus on the other elements to autism, and the 'clinically relevant' picture is also far from complete based on this study alone. Indeed, other text in the discussion provide further clues as to the probable inclination of the authors: "We believe that this study in part reached the “lost generation” of autistic adults... many of whom appear to have turned to social media for support and kinship, sometimes after many disappointing encounters with clinicians and scientists." Emotive language such as 'Lost generation' really shouldn't be in a science paper without [strong] corresponding evidence.

What else? Well the authors did acknowledge some shortcomings in their study: "the on line format limited our ability to ascertain that robust diagnostic procedures had been used in all cases" and: "The self-report format also makes it possible that some participants erroneously reported an official diagnosis" (erroneously?) but perhaps more is needed to be said about participants ("the vast majority were indeed very cognitively able") and onward the applicability of results to other parts of the autism spectrum. It would also have been useful to include a few other (self-report) measures of other conditions/labels where autistic characteristics overlap, just to see...

I do think Wiskerke et al have tapped into a increasingly important research 'need' for some of those on the autism spectrum - masking - and how such behaviour does seem to impact on quality of life for quite a few people. We need a lot more research on this topic, and yes, there also needs to be some further analysis of what social accommodations could be made too, bearing in mind such understanding needs to come from lots of different quarters of society (see here). I'd also like to acknowledge the fact that one of the authors on the Wiskerke took the time to converse (on Twitter) with me about their paper, which was rather encouraging.

But still, I can't shake the idea that the methodological shortcomings of this study and the sweeping interpretations imply caution before any generalisations are made as a result. The fact also remains that self-identifying as being autistic/having autism is not the same as receiving a formal diagnosis of autism, however much people might want this to be true or find 'kinship' with the autism spectrum...

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[1] Wiskerke J. et al. Camouflaging of repetitive movements in autistic female and transgender adults. bioRxiv. 2018. Sept 10.

[2] Mandy W. et al. Sex differences in autism spectrum disorder: evidence from a large sample of children and adolescents. J Autism Dev Disord. 2012 Jul;42(7):1304-13.

[3] Kupferstein H. Evidence of increased PTSD symptoms in autistics exposed to applied behavior analysis. Advances in Autism. 2018; 4: 19-29.

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Exclusion diet plus prebiotics for [some] autism?

"To our knowledge, this is the first study where the effect of exclusion diets and prebiotics has been evaluated in autism, showing potential beneficial effects."

So said the results reported by Roberta Grimaldi and colleagues [1] and the findings of their study attempting to "understand the impact of diet on GM [gut microbiota] composition and metabolism in ASD [autism spectrum disorder] children and to investigate the modulating potential of B-GOS® intervention on these parameters."

The study by Grimaldi et al was research registered (see here) and included the 'gold-standard' research design: "A randomised, double-blind, placebo-controlled" study. Researchers divided 30 children diagnosed with an ASD into two groups (A and B), which were subsequently further divided into two groups depending on whether they followed an exclusion diet - "mainly gluten and casein free" - or an unrestricted diet based on the analysis of 4-day food diaries. Within those subdivided A and B groups, half received a placebo supplement of maltodextrin whilst the other half received a "prebiotic B-GOS® mixture" over a 6-week period. As well as including 'run-in', 'beginning of treatment' and 'end of treatment' periods, researchers also included a follow-up period of 2 weeks at the end of the study where various behavioural and physiological measures complemented their use during the experimental period.

Results: there were quite a few results reported as a function of baseline variables such as whether or not participants were following an exclusion diet or not, and as a function of the intervention(s). Behaviourally (probably most importantly), researchers reported that: "Results showed consistent reduction over time in anti-sociability score in children on the combination of the exclusion diet and B-GOS intervention, with the most apparent difference occurring at follow-up." This was measured using the autism 'rising' instrument called the A-TEC (see here) and also complemented other results based on the use of the autism spectrum quotient (AQ). As far as I can make out, all other behavioural and psychometric measures used - the "empathy and systemising quotient (EQ-SQ)... and the Spence’s Children Anxiety Scale-Parent version (SCAS-P)" - did not show any significant changes over the study duration.

Gastrointestinal (GI) symptoms were also examined during the Grimaldi study as per the use of "daily questionnaires for GI function and symptoms" and the utilisation of that fabulous graphical resource, the Bristol stool chart. Authors reported no significant changes/differences as a consequence of intervention, although: "Significantly lower scores of abdominal pain (P < 0.05) and bowel movement (P < 0.001) were reported in children following exclusion diets" at baseline. Interesting, in light of other independent results (see here).

Grimaldi and colleagues also provide quite a lot of data following their examination of fecal and urine samples taken over the course of their investigation. This is perhaps not unexpected given their previous research interests in this area and the proud reputation earned at one of the affiliated institutions. The results? Lots of them. Perhaps the most important intervention-wise was the finding of a "significant increase of Lachnospiraceae family" following B-GOS® intervention. The authors talk about this in terms of the production of butyrate (as per their previous research) and the (positive) reputation this stuff is starting to garner.

Other details? Well, going back to the baseline assessment of samples as a function of the use of an exclusion diet or not, there are some interesting findings. So: "Before prebiotic B-GOS® intervention, we evaluated the nutritional impact of exclusion diets (GFCF) and our results showed deficiency in vitamin D intake, which was significant in children on unrestricted diets." This kinda ties into other research which observed that the 'horror' that is a gluten-free, casein-free (GFCF) diet in relation to autism might actually not be that horrible in nutritional terms (see here). I'm also minded to bring in other recent research which suggested that a GF diet might be a bit of a 'fixer' when it comes to vitamin D deficiency issues under certain clinical circumstances [2]. I say this minus any sweeping generalisations or universal application to the label of autism.

Overall the Grimaldi findings are interesting and suggest further investigations are required on the use of prebiotics and diet in autism; perhaps complementing the still-growing interest in the gut microbiota and autism (see here for one example). Mindful also that diet can itself be seemingly affect gut bacterial composition too [3]. As they stand however, the current results aren't yet a glowing endorsement of B-GOS® intervention 'for' autism, mindful of the small participant group eventually included for study and the relatively short-term nature of the Grimaldi trial. We'll see where this goes... although next time, I'd also like to see a more prominent statement about any harms or side-effects encountered or not during the study period. I assume 'not' in the current study but...

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[1] Grimaldi R. et al. A prebiotic intervention study in children with autism spectrum disorders (ASDs). Microbiome. 2018 Aug 2;6(1):133.

[2] Zingone F. & Ciacci C. The value and significance of 25(OH) and 1,25(OH) vitamin D serum levels in adult coeliac patients: A review of the literature. Dig Liver Dis. 2018 Aug;50(8):757-760.

[3] Berding K. & Donovan SM. Diet Can Impact Microbiota Composition in Children With Autism Spectrum Disorder. Front Neurosci. 2018 Jul 31;12:515.

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The estimated prevalence of childhood autism in Nepal (based on the AQ-10)

I read with some interest the paper by Michelle Heys and colleagues [1] talking about an estimated prevalence rate of autism in Nepal. The figure they arrived at was: "an estimated true prevalence of 3 in 1000 (95% confidence interval 2–5 in 1000)."

Unless you are Nepalis or really, really interested in the epidemiology of autism worldwide (raises hand slowly), you're probably not going to be particularly 'excited' by such findings. I'm blogging about them however, because there are a couple of points of interest to take from the Heys paper. Not least that the (estimated) prevalence of autism seems to be really, really low in Nepal. I'm also quite interested in the assessment tool used - the Autism Spectrum Quotient (AQ) - and some comments made about autism from some of the parents of participants as potentially also affecting the results obtained.

The Heys study is actually a few studies included in one peer-reviewed write-up. First and foremost, researchers identified a potentially suitable population-based screening tool for autism, then adapted and translated said screening tool "in the Nepali language", then checked the acceptability of the translated assessment tool and finally, set about administering the translated assessment tool and arriving at an estimated prevalence rate. As I've already mentioned, the assessment tool settled on was the AQ-10. The decision to use this tool was taken because out of 12 assessment schedules looked at, the AQ-10 'fitted best' researchers criteria (including being free to use).

The estimated prevalence rate was arrived at on the basis of over 4000 children being 'screened' using the AQ-10. "Fourteen children scored > 6 out of 10 [on the AQ-10], indicative of elevated autistic symptomatology, of which 13 also screened positive for disability." That 'screened positive for disability' refers to the "report of social and communication difficulties, as well as physical, learning and behavioral disability using the Module on Child Functioning and Disability (MCFD) produced by UNICEF and the Washington Group on disability statistics... for use in children and young people aged 2–17 years." The authors go on to mention that those 14 children who scored 6 or greater on the AQ-10 probably reflected "children with complex needs and more likely more severe autism." Indeed they also note: "Of those children who screened positive for autism symptomatology, almost all also screened positive for physical, learning and behavioral disabilities." Yet again, autism rarely appears in some sort of diagnostic vacuum (see here).

I'll freely admit that I am ever-so-slightly critical of the AQ and its application to autism screening. I'm critical because autistic traits are not necessarily something exclusive to a diagnosis of autism (see here for one example) and short screening instruments for autism like the AQ are rarely able to tease out the possibility of other diagnoses being pertinent (perhaps even more pertinent than the label of autism). When it comes to the use of the AQ as a screener for possible adult autism, well, one only needs to look at the 'English experience' of adult prevalence estimate studies to see that results weren't exactly optimal (see here) (albeit based on the use of the AQ-20 [2]).

Do I therefore agree with the use of the AQ-10 in the Heys Nepal autism prevalence study? Well, sitting in a high-and-mighty 'with hindsight' position (😉) I would have perhaps gone with something a little more comprehensive or at least included another instrument alongside. I say this on the basis that 10 questions don't really provide enough detail when it comes to big claims about estimated autism prevalence (as per the title of the paper). The fact also that the majority of the 14 children picked up by the AQ-10 as showing 'elevated autistic symptomatology' also presented with a complex pattern of disability (including 'learning and behavioral disability) is also at odds with the typical guidance on the use of the AQ-10: "A quick referral guide for parents to complete about a child aged 4-11 years with suspected autism who does not have a learning disability." This bearing in mind also that the authors used the AQ-10 in a second wave of data collection (the MCFD was used in the first wave when such 'learning and behavioral disability' would have been initially picked up). I don't want to be too critical, but...

The second reason for blogging about the Heys paper concerns some of the comments made about autism in the context that typically Western views on autism - abilities and disabilities - are not necessarily shared the world over and might have affected the results obtained. I'm not going to recite the quotes included in the Heys study but let's just say that the point made by the authors: "would find a potential diagnosis of autism challenging to accept or endorse" kinda sums up the feelings portrayed by some parents. Bearing in mind, the AQ-10 was completed by parents or primary caregivers, and well, it's not beyond the realms of possibility that some parents may have put a more 'positive spin' on some of their responses...

There are other important points raised in the Heys paper - "children who screened positive for autism symptomatology were more likely to be stunted... Nutritional deficits in children with disabilities and learning difficulties are common and can not only be a cause of cognitive deficits, but also contribute to the failure to reach full developmental potential in the presence of a developmental condition" - but I've gone on enough for now. Suffice to say that the very conservative prevalence estimates produced by Heys et al are probably not a true reflection of the scale of autism in Nepal. Much more research is indicated.

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[1] Heys M. et al. The Estimated Prevalence of Autism in School-Aged Children Living in Rural Nepal Using a Population-Based Screening Tool. J Autism & Dev Disord. 2018. May 31.

[2] Brugha TS. et al. Validating two survey methods for identifying cases of autism spectrum disorder among adults in the community. Psychol Med. 2012 Mar;42(3):647-56.

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Temporal armchair diagnosing taken to the max: 'How Do We Explain ‛Autistic Traits’ in European Upper Palaeolithic Art?'

Headlines aplenty...

I'm not a great fan of 'armchair diagnosing' also known as 'diagnosing at a distance'. It's speculative, often inaccurate and runs the real risk of ruining lives.

The remote diagnosing of psychiatric and behavioural disorders is a particular bugbear of mine. It's something that autism research and practice in particular has had to endure for quite a few years, as a volley of historical figures for example, were revealed to be supposedly autistic. Such musings also add a temporal aspect to proceedings.

The paper published by Penny Spikins and colleagues [1] takes such temporal armchair diagnosing to the absolute max, with their contribution to the "long standing debate about the existence of ‘autistic traits’ in European Upper Palaeolithic art." Some of the media that followed these findings really went to town, as per headlines such as 'Ice Age cave artists were AUTISTIC' (capital letters were already included in the headline, not added by me - see above) and 'Autism shaped the art of survival'. Wow. All of that information from a few paintings and carvings...

So how did the the authors and the lay media arrive at such a conclusion?

Well, first and foremost Spikins et al did not say that the makers of such early art were 'autistic'. They focused on autistic traits, and in particular the idea of an "extreme local processing bias" or attention to detail trait that seems to accompany the diagnosis of autism (for some). Importantly, they note that: "Local processing bias is common in autism but also seen in individuals without autism" and "‘Autistic traits’ in Upper Palaeolithic art do not necessarily signify the work of an individual with autism." So, from the outset, we can probably do away with that rather sweeping [diagnostic evidence-free] media headline on Ice Age cave artists being autistic.

Quite a lot of the Spikins paper focuses on what's been observed - directly observed - in some of those diagnosed as being on the autism spectrum when it comes to artistic talent, which is then 'extrapolated' to such prehistoric artists. This includes some rather nice pictures drawn by individuals with autism who expressed a "marked local processing bias" compared with age-matched drawings from non-autistic individuals. We're also told that the use of the (very) famous 'are you autistic?' self-report screener that is the Autism Spectrum Quotient (AQ) by the authors, revealed that "individuals with a very high autism quotient (AQ) of 32 or above, which is taken as indicative of an autism spectrum condition within a population sample were statistically much more likely than neurotypical individuals (i.e. those with a lower AQ score) to have an interest in and experience of art outside of any school curriculum." 'Indicative of an autism spectrum condition'? Well, we'll see. And I still have some problems with what comes under the term 'neurotypical' too (see here).

Of course you can perhaps see the issue here. Take one block of 'evidence', some of it based on individual case reports and some of it based on an 'autism' screener that probably picks up an awful lot more than 'just autism' (see here and see here and see here for examples), correlate and correlate some more and hey presto, we reach the conclusion that the art must have been drawn by someone expressing an autistic trait or even someone who was autistic.

A testable hypothesis? No, it's not. We don't know who drew those paintings or made those carvings. We don't know anything about them personally and we certainly don't have any evidence about whether they expressed any significant autistic or any other kind of trait. For all we know, the paintings or carvings could also have been made by more than one person; a family or group effort if you like. We just don't know because, well, those artistic depictions were made thousands and thousands of years ago before the tools that help us record history were even a twinkle in the cosmic eye.

I don't want to come across as poo-pooing such 'observations' stressing how autistic traits are not necessarily a new thing because, in essence, I do think that some autistic traits have probably been with us from our earliest evolutionary times (see here). I say that on the basis that the traits of autism are not some 'magical' behaviours that are completely distant from the human experience; more likely they represent the extremes of what is typically seen in the general population at particular ages and stages and environments. Taking such logic back in an evolutionary sense, one can for example see how something like an 'attention to detail' could be a good survival skill if your life depended on it.

But I do think one has to be very, very cautious about such research and any 'feelgood' factor it might attempt to generate or put forward. Autism, as a clinical definition, only really came about in the last hundred years or so, and for many, any benefits derived from a 'marked local processing bias' have to be balanced with the possible downsides to such directed focus (e.g. increased rumination and anxiety). I'd also add in that the idea that Palaeolithic Art (or indeed, any kind of art) merely comes about as a result of traits that are noted in the context of psychopathology is a pretty dangerous path to take. It risks boiling down human efforts such as creativity and artistic skill to nothing more than diagnostic characteristics and feeds into narratives such as the "creativity is akin to insanity" headlines of not so long ago (see here). As I've said before, people are so much more than the labels they've received or the diagnostic term they identify with.

In short, Palaeolithic art is interesting and adds to our understanding of how we evolved. But it simply cannot provide an accurate window on any states and traits of those who created it...

To close, there's a wedding on today apparently. Best wishes to the happy couple. And not to make light of our Royal Family, but The Windsors TV show is absolute comedy gold (particularly Harry Enfield)...

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[1] Spikins P. et al. How Do We Explain ‛Autistic Traits’ in European Upper Palaeolithic Art? Open Archaeology. 2018; 4: 262-279.

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Higher autistic traits in those attending transgender health services don't necessarily mean autism

There are some key messages to take from the findings reported by Anna Nobili and colleagues [1] following their examination of "self-reported autism spectrum quotient-short (AQ-short) [scores] in a transgender clinical population." Not least that when compared with a control group - "cisgender individuals" - there "were no significant differences in the number of people who presented with scores suggesting a possible diagnosis of ASC [autism spectrum condition(s)]."

OK, before heading further into the Nobili findings I think it might be worthwhile setting the scene a little. So, for quite a while now there has been some increasing interest in how autism or at least some of the traits of autism, *might* be over-represented among those presenting with gender dysphoria (see here). Gender dysphoria, according to the UK NHS Choices website is "a condition where a person experiences discomfort or distress because there's a mismatch between their biological sex and gender identity." Allied to other peer-reviewed research looking at gender identity [2], sexual preferences in the context of [some] autism (see here), and combined with quite a sweeping *theory* talking about an 'extreme male brain' in the context of autism (see here), and well, let's just say some speculation about a link between some autism / autistic traits and elements of gender and sexuality has been noted. And indeed, continues to be noted [3]...

Nobili et al - including one author who is rather central in autism research circles to the promotion of that extreme male brain theory - examined AQ responses in some 650 matched pairs (transgender matched with cisgender). Among the transgender participants: "A total of 260 people (39.6%) in each group were assigned female at birth whilst 396 (60.4%) were assigned male." It's worthwhile noting that AQ is a self-report questionnaire, and whilst heralded in several quarters as a good 'are you autistic?' screener, there are some people - including me - who have some reservations about it's 'universal' usefulness to just autism (see here and see here for examples). I'll come back to this shortly...

As per the opening paragraph to this post, the numbers of participants "indicating possible ASC caseness" did not differ significantly between the groups. So, around 33% of the cisgender control group hit a score of 70 or more on their self-report responses to the AQ compared with 36% in the transgender group. The authors did detect a statistically significant difference in possible caseness when looking at those assigned female at birth in the transgender group but not for males. A similar finding has been noted in other independent studies [4]. Nobili and colleagues however concluded that their findings were in line with other observations in adults in that: "there is no evidence of increased rates of autism in transgender populations as a whole."

Going back to my reservations around the AQ as an exclusive autism screener, I also noted something important reported by Nobili and colleagues: "High AQ scores may not be indicative of the presence of an autism spectrum condition as the difference between groups mainly related to social behaviours; such scores may be a reflection of transgender people’s high social anxiety levels due to negative past experiences." I was really intrigued by this finding and interpretation, particularly in light of other recent peer-reviewed speculation by Jack Turban [5] who suggested that: "ASD [autism spectrum disorder] symptoms [in transgender youth] may represent social deficits that are secondary to social stress and deprivation, as transgender youth suffer high rates of peer and family rejection." On a previous blogging occasion, I've also discussed research suggesting that something like a generalised anxiety disorder (GAD) may 'inflate' responses/scores on the AQ (see here). Given that anxiety is an all-too-often bedfellow accompanying a diagnosis of autism, I'd be interested to see quite a bit more study on this topic in the context of AQ use. Y'know, perhaps alongside some more formal measures of anxiety both in relation to autism and also more readily pertinent to the subject matter analysed by Nobili et al. And, outside of just anxiety, other clinical features/conditions might also be thrown into the research mix [6]. Insofar as the idea that mental health may also be a topic requiring more focus in respect of the transgender population, I'll bring to your attention some other recent research by Becerra-Culqui and colleagues [7] on this point.

There is a further scheme of work to follow in this area, and I'll be interested to see what further results turn up, particularly with regards to females assigned at birth with gender dysphoria. And since I've mentioned the AQ and (once again) my reservations, I'll direct you to another paper published in the same journal at roughly the same time as the Nobili findings, where the AQ was again 'implied' as being equal to the presence of autistic traits [8]. And yet again, another example where one has to be very, very careful about making that 'exclusively autistic traits' link...

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[1] Nobili A. et al. Autistic Traits in Treatment-Seeking Transgender Adults. J Autism Dev Disord. 2018. April 13.

[2] Cooper K. et al. Gender Identity in Autism: Sex Differences in Social Affiliation with Gender Groups. J Autism Dev Disord. 2018. April 28.

[3] van der Miesen AIR. et al. Prevalence of the Wish to be of the Opposite Gender in Adolescents and Adults with Autism Spectrum Disorder. Archives of Sexual Behavior. 2018. May 7.

[4] Vermaat LEW. et al. Self-Reported Autism Spectrum Disorder Symptoms Among Adults Referred to a Gender Identity Clinic. LGBT Health. 2018 May 9.

[5] Turban JL. Potentially Reversible Social Deficits Among Transgender Youth. J Autism Development Disord. 2018. May 12.

[6] Lugnegård T. et al. Asperger syndrome and schizophrenia: Overlap of self-reported autistic traits using the Autism-spectrum Quotient (AQ). Nord J Psychiatry. 2015 May;69(4):268-74.

[7] Becerra-Culqui TA. et al. Mental Health of Transgender and Gender Nonconforming Youth Compared With Their Peers. Pediatrics. 2018. April 16.

[8] Loureiro D. et al. Higher Autistic Traits Among Criminals, But No Link to Psychopathy: Findings from a High-Security Prison in Portugal. J Autism Dev Disord. 2018. April 12.

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"adult patients with CFS report few autistic traits in the self-report instrument, the AQ"

The findings reported by Indre Bilevicute-Ljunger and colleagues [1] tap into something of a developing interest I have on this blog: whether there is 'clinical overlap' between the diagnosis of chronic fatigue syndrome (CFS) (also known as ME or myalgic encephalomyelitis) and the diagnosis of autism or autism spectrum disorder (ASD) (see here).

Just before anyone gets the wrong end of the stick here, I'm not at all insinuating that CFS/ME and autism are one and the same. They are not. As per a previous research foray into the diagnostic borderlands of CFS/ME [2] I have however long been struck by how there may be some 'shared' symptoms relevant to both labels; particularly with reference to the presence of perceptual and motor issues ("auditory hyperacuity", "problems of balance", "walking problems"). Added also to a number of anecdotal reports suggesting that a diagnosis of autism is seemingly not protective against receipt of a diagnosis of CFS/ME, and it strikes me that there could be more investigations required in this area. At the time of writing however, there is very little in the peer-reviewed research domain examining any such 'overlap'.

Bilevicute-Ljunger et al - including the notable name of Susanne Bejerot on the authorship list (see here) - set out to examine any potential 'relationship' between autism and CFS by means of assessing three participant groups with everyone's favourite 'are you autistic?' self-report measure, the Autism-Spectrum Quotient (AQ). Said groups included those diagnosed with CFS (n=59) , those diagnosed with autism (n=50) and a group headed under the rather uninformative label of 'healthy controls' (HC) (n=53). The presented results showed that those diagnosed with ASD "scored significantly higher on the AQ than the CFS group and the HC group" and that: "No differences in AQ scores were found between the CFS and HC groups." Authors therefore concluded that: "Despite clinical observations of symptom overlap between ASD and CFS, adult patients with CFS report few autistic traits in the self-report instrument, the AQ."

Sounds pretty straight-forward eh? Well, hold on just a moment...

"The choice of instrument to assess autistic traits may influence the results." That was another line included in the Bilevicute-Ljunger paper, in conjunction with the idea that the AQ may very well be 'testing for' something in the context of autism, but that doesn't mean it is without issues in terms of things like specificity for autism (see here and see here). Indeed, I'll also take you back to a recent blog post (see here) which kinda said everything that needed to be said in terms of the [general] current state of adult questionnaires and screening measures for autism [3] including the AQ: "Evidence suggests some utility of diagnostic measures in identifying autism spectrum disorder among clinic referrals, although specificity for diagnosis was relatively low." Ergo, it is not completely unlikely that scoring high on the AQ and various other instruments *might* not necessarily mean just autism is present. I'll be coming back to the issue of AQ yet again on this blog quite soon.

Without trying to sound like someone who has a bee in their bonnet about the AQ not being a particularly great 'autism-specific' measure, I would like to see some further work done looking at any overlap between symptom presentation in CFS/ME and the same with regards to autism. I'd perhaps be minded to suggest that science starts to look at CFS/ME symptoms in autism rather than the other way around first and foremost. This would provide a baseline to see how prevalent CFS/ME in diagnosis or traits might be when an autism diagnosis is in the frame, particularly extending into adulthood. It might also provide some 'clues' as to whether shared or overlapping genetics / biology / physiology could be further investigated (hint: immune functions such as autoimmunity, oxidative stress, gut microbiota, etc. might be places to look) minus the psychobabble that both conditions have had to endure over the years. I'd similarly be interested in the idea that the sex ratios are seemingly opposing when it comes to ME/CFS and autism, and what that might mean for ensuring that screening for autism or autistic traits in relation to ME/CFS takes account of the chatter about sex/gender *potentially* influencing symptoms profiles (see here) and things like the female camouflage effect (see here)...

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[1] Bilevicute-Ljunger, I. et al. Patients with chronic fatigue syndrome do not score higher on the Autism-apectrum quotient than healthy controls: comparison with autism spectrum disorder. Scandinavian Journal of Psychology. 2018.  May 8.

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"ASD characteristics in adulthood are differently perceived across age, sex, and informants"

The research tag-team that is Anne Lever and Hilde Geurts have provided peer-reviewed fodder for this blog before (see here and see here). Without wishing to cajole their research interests into a specific box, quite a bit of their time seems to be taken up by looking at autism in the context of ageing, alongside how the label of autism does not seem to have a monopoly on the presentation of certain autistic traits.

A recent paper published by this team [1] provides yet more blogging material, specifically focused on testing "the association between age and ASD [autism spectrum disorder] characteristics, including empathy and sensory sensitivity, in adults aged 19–79 years." A scientific hat-tip is offered to other research in this area [2] that previously observed that: "older age was associated with higher ratings of ASD traits and better cognitive performance."

Drawing on data derived from a participant group numbering above 400 (N=237 with autism and N=198 without autism) spanning the age ranges, a variety of self-report and informant-report (family members, friends, other significant others) were utilised. I should point out that the autism participant group seemed to be represented by the 'more able' part of the autism spectrum (I don't use the term 'functioning') insofar as most either being diagnosed with Asperger syndrome or PDD-NOS (pervasive developmental disorder - not otherwise specified), being predominantly independent or living with a partner or housemate in residential status terms and also with that reliance on self-report used throughout the study kept in mind. This is worth knowing given other discussions on under-represented groups when it comes to scientific study (see here) and how representative autism research may or may not be to the entire spectrum.

Among the measures included for analysis we have an old favourite - the Autism-Spectrum Quotient (AQ) - as well as the Interpersonal Reactivity Index (IRI) (measuring various aspects of empathy) and the Sensory Sensitivity Questionnaire (SSQ) (examining sensory hyper- or hyposensitivity). Obtained results were collated and subjected to quite a few statistical analyses.

Results: noted as a 'group difference' findings were reported observing that: "Adults with ASD reported higher scores on the SSQ and on all subscales of the AQ than adults without ASD." This is pretty much what would be expected, despite any qualms I might have about what the AQ actually measures (see here for more of them). Sensory issues being reported as being greater in those with a diagnosis of autism also ties in well with their inclusion in the DSM-5 schedule for diagnosing autism or ASD (see here).

Then: "Within the ASD group, age-related differences were observed in self-reported ASD traits and sensory sensitivity, with a peak among middle-aged adults." Alongside that previously 'hat-tipped' study, the authors conclude that "ASD characteristics are more heavily experienced in middle adulthood than in younger or older adults." This is interesting from quite a few perspectives; bearing in mind that such findings say nothing about the expression of autism in childhood and early adulthood. Appreciating that the self-report of autism or sensory traits may not be the same as everyday autism expression, such findings *might* have some relevance to various issues such as the rise and rise of adult autism diagnoses being given and indeed, how a diagnosis of autism for some (a few?) might not be a 'lifelong' issue (see here). I know that last point raises blood pressure in some quarters as words like 'masking' are banded around (with the need for far greater study), but there is good reason to think that like many other conditions/labels, autistic behaviours and/or traits ebb and flow according to environment and perhaps other factors, such as the presentation of comorbidity for example (as per the author's other work [3] already mentioned). In short, the presentation of autism is probably dynamic and fluidic, rather than just a static thing.

Onward: "we replicated earlier findings that females with ASD had more sensory issues and reported more ASD characteristics than males... whereas females without ASD manifested fewer ASD traits than non-ASD males.". Females with ASD (74 females vs. 163 males) 'reported more ASD characteristics than males'? Intriguing - "ASD females reported higher scores than ASD males on the AQ total score" - to say the least in light of other [childhood] findings [4] but not without cautions. I go back once again the question of what the AQ is actually measuring and whether for example, the typically higher rate of mood disorders generally noted in females could be a potential confounder when it comes to AQ scores in the context of that previous reference [3] from the authors. This area requires further investigation.

Finally: "Overall, the current results show poor to fair agreement between self- and other-reports of well-known proxies, even though the agreement of the overall group was similar to those previously reported for social responsiveness." Again, some potentially important lessons to be learned here insofar as the 'meaning of autism' to a person and those around them. Indeed I note the authors' offer one explanation: "the self may be more accurate about traits that describe unobservable thoughts and feelings due to privileged access (e.g. feelings of empathy and sensory sensitivity), whereas an informant would be more accurate about observable behavior (e.g., ASD traits)." Again, jumping back into 'hot potato' territory, such a finding may have implications for the whole 'self-diagnosed vs. formal diagnosis' debate that still continues at a pace (see here).

There is quite a bit more to take in from this latest paper from Lever & Geurts and definitely some food for thought. I'll leave you however with one final quote from the authors that is perhaps one of the more important take-away points from their study: "it is important to repeatedly assess self-reported ASD characteristics during adulthood." Who would argue with that in terms of getting wants, wishes, needs and requirements accurate and up-to-date?

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[1] Lever AG. & Geurts HM. Is Older Age Associated with Higher Self- and Other-Rated ASD Characteristics? Journal of Autism & Developmental Disorders. 2018. Jan 18.

[2] Happé FG. et al. Demographic and Cognitive Profile of Individuals Seeking a Diagnosis of Autism Spectrum Disorder in Adulthood. J Autism Dev Disord. 2016 Nov;46(11):3469-3480.

[3] Geurts HM. et al. Autism Characteristics in Older Adults with Depressive Disorders. The American Journal of Geriatric Psychiatry. 2016; 24: 164-169.

[4] Øien RA. et al. Sex-Differences in Children Referred for Assessment: An Exploratory Analysis of the Autism Mental Status Exam (AMSE). J Autism Dev Disord. 2018. Feb 8.

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